Archive for March, 2012

I don’t know why I’ve had people ask me lately if you can reverse pressure ulcer stages for Stage I and II ulcers, but you can’t, and CMS has clarified M1324 in a recent Q&A.

CMS also clarified an M1307 question dealing with a pressure ulcer that progressed from Stage I to Stage II during the episode:

Question: If the patient had a Stage I pressure ulcer at SOC that progressed to a Stage II, how do we answer M1307 at discharge?
CMS Answer: If a patient had a Stage I pressure ulcer at SOC/ROC and it advanced to a Stage II by discharge, Response “1-Was present at the most recent SOC/ROC assessment” would be appropriate due to the fact that the ulcer, caused by pressure, was present at the most recent SOC/ROC assessment, even though it was a Stage I at that time.

The HHS Office of the Inspector General conducted a study looking at home health claims from 2002-2008 and found that$432 million in Medicare monies were inappropriately paid either because medical necessity was not established or coding was inaccurate. Millions more dollars were lost to CMS or HHAs because of upcoding or downcoding.

The number of HHAs grew from 7,052 to 9,801, and increase of 39 percent. Medicare spending on home health increased 84 percent from $8.5 billion in 2000 to $15.7 billion in 2007. The sharp rise in payments created the push to investigate payments.

HHS reviewed the claims of almost 500 beneficiaries to see whether Medicare coverage requirements were met.

The office found that 22 percent of claims were in error because services were not medically necessary or claims were coded inaccurately, resulting in $432 million in improper Medicare payments. Also, HHAs upcoded about 10 percent ($278 million) of claims and downcoded about 10 percent ($184 million) of claims.

OIG believes it needs to investigate more to determine what services are met and what potential for fraud is involved.

Question: Our clinician reported an ostomy as a surgical wound in the OASIS M1340, Surgical Wound item. The clinician no longer works for the agency, so we cannot contact her about the error. Can this OASIS change be made by the DON without speaking to the clinician?
CMS Answer: You have described a situation where a true OASIS scoring error was discovered during the audit process. The assessment was complete. The patient had an ostomy, a clear, non-disputable fact based on the entire clinical record. The assessing clinician responsible for completing the assessment misunderstood, wasn’t aware, or made an error based on the OASIS scoring guidance, which states all ostomies are excluded as surgical wounds in M1340.
HHAs should have a policy and procedure for correcting errors that involves the assessing clinician. The policy should follow established clinical record professional practice standards and guidance found in relevant CMS regulations and guidance. Normally, if an error is identified through audit or review, the individual who made the original entry into the patient’s record would, whenever possible, make the necessary correction by following agency policy. A correction policy may allow the auditor who found the error to contact the clinician, discuss the discrepancy in the medical record and make the correction following your policy including information such as who discovered the error, and the date and time of communication with the assessing clinician who agrees that it was an error. Correction of an error will not impact the M0090, Date Assessment Completed.
In a case where, as you have described, the original documenter is not available, the clinical supervisor or quality staff may make the correction to the documentation following the correction policy. The supervisor must document why the original assessing clinician is not available to make the correction and how the error was identified and validated as a true error. When corrections are made to assessments submitted to state, you must determine the impact of the correction on the POC, HHRG, the Plan of Treatment, RAP and make corrections to those documents and billing, as applicable.
When the comprehensive assessment is corrected, the HHA must maintain the original as well as subsequent corrected assessments in the patient’s clinical record per requirements at 42 CFR 484.48.

In an announcement, the Centers for Medicare & Medicaid Services’ (CMS) Office of E-Health Standards and Services (OESS) said it will not initiate enforcement action against any non-compliant entities for an additional three (3) months, through June 30, 2012,for updated HIPAA transaction standards (ASC X12 Version 5010, NCPDP Versions D.0 and 3.0).

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Health plans, clearinghouses, providers and software vendors have been making steady progress: the Medicare Fee-for-Service (FFS) program is currently reporting successful receipt and processing of over 70 percent of all Part A claims and over 90 percent of all Part B claims in the Version 5010 format. Commercial plans are reporting similar numbers. State Medicaid agencies are showing progress as well, and some have made a full transition to Version 5010.

The rate of leg and foot amputations among U.S. adults aged 40 years and older with diagnosed diabetes declined by 65% between 1996 and 2008, according to a new study by the Centers for Disease Control and Prevention (CDC).

The CDC attributes better blood glucose control, foot care, and diabetes management, along with a drop in heart disease, as likely reasons that the number of amputations has fallen.

Diabetes is the leading cause of nontraumatic amputations of feet and legs among U.S. adults.

The age-adjusted rate of nontraumatic lower-limb amputations was 3.9 per 1,000 people with diagnosed diabetes in 2008 compared to 11.2 per 1,000 in 1996.

Join the Centers for Medicare & Medicaid Services National Medicare Training Program monthly webinar. Get the most up-to-date program information for professionals and volunteers who work with seniors and people with disabilities.

Just a reminder that the enforcement for the Version 5010 upgrade begins March 31.

CMS offers some advice on things to watch for (this is aimed at providers):

An Increase in Rejections or Denials of Claims

An increase in rejections or denials of claims may be an indication that there is not sufficient or correct data provided to meet Version 5010 standards. Partners, such as payers, also have a part in correcting this issue, since forwarding, converting, or formatting data can result in rejections or denials. Monitor your claims closely to determine the reasons for rejection or denial of claims and coordinate with payers to ensure that data is properly processed to avoid claim delays.

Issues with Non-Electronic Funds Transfer (non-EFT) Payments
Version 5010 includes changes to claims formatting, including a full nine-digit ZIP code and inclusion of provider billing address. Submitting claims with only a five-digit zip code will result in rejection. If your practice has not submitted the correct billing or mailing address as part of your Version 5010 claim, your non-Electronic Funds Transfer (non-EFT) payments or Explanation of Benefits (EOBs) information may be mailed to the wrong physical location. Make sure to coordinate with your payers to verify how they use enrollment information and process claims data, as this will also be affected by the mailing address on file. Being diligent in tracking your claims and remittances (EOBs) will help identify and address any issues that may arise.

Formatting Discrepancies with Partners
Your trading partners should also have upgraded to Version 5010; however, your organization may interpret the new standards differently than your external partners, which can result in rejected claims. You should coordinate with your payers and/or clearinghouse to determine any gaps or discrepancies in claims submissions. You and your partners should monitor claims that are automatically transferred between payers and address new response formats or data as claims are processed.

A survey of senior healthcare professionals shows that a one-year ICD-10 would be “costly, but manageable,” but a two-year delay could be “catastrophic.”

Data exchange group Edifecs polled the professionals, the majority of whom also said that the delay will do nothing to improve readiness for the implementation, but could hinder other healthcare reform efforts.

“Costs are likely to spiral higher, and valuable resources may be lost as the industry waits for the outcome of CMS’ process to determine whether the deadline will slide,” the survey states.